Axel Price
PFD Report
All Responded
Ref: 2024-0195
All 1 response received
· Deadline: 10 Jun 2024
Coroner's Concerns (AI summary)
A national lack of clear guidance and multi-agency understanding for vulnerable young people transitioning from child to adult mental health services leads to inadequate support and patients falling through service gaps.
View full coroner's concerns
During the investigation, This case identified that there is a lack of clear understanding of the risk or accountability between the agencies when a young person transitions from CAMBS services at the age of 18 to adult services. The expert who provided evidence in this case said that this was a well-recognised problem and whilst services across the country had tried to address this, there was a lack of national guidance and provision. In this particular case Axel was particularly vulnerable. He was born Yasmin Price but identified as a male from a young age. He had struggled emotionally during his teens and had indulged with alcohol and drugs. He had been detained on a number of occasions due to his mental health. At the age of 18 he transitioned to adult services but there was a lack of a recognised pathway for him. In the lead up to his death he had been discharged from a mental health provision following his arrest for criminal offences. He was then discharged from the hospital and subsequently the Police station to temporary accommodation. There was little shared understanding between agencies of how Axel should best be supported and therefore he appeared to fall between the services. Substantial changes have been made locally by Sussex Partnership Foundation NHS Trust around the transition of those from CAMBS to Adult health services but looking at other Prevention of Future Death Reports this is not just a local issue. There is a lack of national guidance and support in relation to the multi-agency approach that is needed to support those young people transitioning to adult health and social care services. Unless this is addressed nationally, sadly other deaths will occur.
Responses
Action Planned
The DHSC acknowledges concerns about transitions from children's to adult mental health services and highlights the NHS Long Term Plan's aim for a comprehensive offer for 0-25 year olds. They describe extending current service models and offering grants for senior mental health lead training in schools. (AI summary)
The DHSC acknowledges concerns about transitions from children's to adult mental health services and highlights the NHS Long Term Plan's aim for a comprehensive offer for 0-25 year olds. They describe extending current service models and offering grants for senior mental health lead training in schools. (AI summary)
View full response
Dear Ms Schofield,
Thank you for your Regulation 28 report to prevent future deaths dated 15 April 2024 about the death of Axel Price. I am replying as the Minister with responsibility for mental health and patient safety.
Firstly, I would like to say how saddened I was to read of the circumstances of Axel’s death and I offer my sincere condolences to his family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention.
Your report raises concerns about the transitions from children and young people’s mental health services to adult services at the age of 18.
We recognise how important it is that young people with mental ill health get the level of care that is appropriate for their needs, and we want to ensure that they have access to the right mental health support, in the right place, and at the right time.
Through the NHS Long Term Plan, local health systems were tasked with delivering a comprehensive offer for 0-25 year-olds to ensure young adults receive appropriate mental health support regardless of their age or diagnostic profile. Between the ages of 16-18, young people are more susceptible to mental illness, undergoing physiological change and making important transitions in their lives. As your report highlights, the structure of NHS mental health services sometimes creates gaps for young people undergoing the transition from children and young people’s mental health services to appropriate support including adult mental health services. The new approach to young adult mental health services for people aged 18-25 will better support the transition to adulthood.
The NHS is extending current service models to create a comprehensive offer for 0-25 year olds that reaches across mental health services for children, young people and
adults. The new model is intended to deliver an integrated approach across health, social care, education and the voluntary sector, such as the evidence-based ‘iThrive’ operating model which currently covers around 47% of the 0-18 population and can be expanded to cover 18-25 year olds.
In terms of providing mental health support up to the age of 18, there are now nearly 500 mental health support teams in place across England, covering 4.2 million children or around 44% of pupils in schools and colleges.
We have also offered all state schools and colleges a grant to train a senior mental health lead to support the introduction of effective, whole school approaches to mental health and wellbeing. Over 15,100 schools and colleges have received a senior mental health lead training grant, including more than 7 in 10 state-funded secondary schools in England.
In addition, we are providing £8 million to fund 24 existing early support hubs across the country – ranging from Exeter to Liverpool. This will improve access for children and young people to vital mental health support in the community, offering early interventions to improve wellbeing before their condition escalates further.
I hope this response is helpful. Thank you for bringing these concerns to my attention.
Thank you for your Regulation 28 report to prevent future deaths dated 15 April 2024 about the death of Axel Price. I am replying as the Minister with responsibility for mental health and patient safety.
Firstly, I would like to say how saddened I was to read of the circumstances of Axel’s death and I offer my sincere condolences to his family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention.
Your report raises concerns about the transitions from children and young people’s mental health services to adult services at the age of 18.
We recognise how important it is that young people with mental ill health get the level of care that is appropriate for their needs, and we want to ensure that they have access to the right mental health support, in the right place, and at the right time.
Through the NHS Long Term Plan, local health systems were tasked with delivering a comprehensive offer for 0-25 year-olds to ensure young adults receive appropriate mental health support regardless of their age or diagnostic profile. Between the ages of 16-18, young people are more susceptible to mental illness, undergoing physiological change and making important transitions in their lives. As your report highlights, the structure of NHS mental health services sometimes creates gaps for young people undergoing the transition from children and young people’s mental health services to appropriate support including adult mental health services. The new approach to young adult mental health services for people aged 18-25 will better support the transition to adulthood.
The NHS is extending current service models to create a comprehensive offer for 0-25 year olds that reaches across mental health services for children, young people and
adults. The new model is intended to deliver an integrated approach across health, social care, education and the voluntary sector, such as the evidence-based ‘iThrive’ operating model which currently covers around 47% of the 0-18 population and can be expanded to cover 18-25 year olds.
In terms of providing mental health support up to the age of 18, there are now nearly 500 mental health support teams in place across England, covering 4.2 million children or around 44% of pupils in schools and colleges.
We have also offered all state schools and colleges a grant to train a senior mental health lead to support the introduction of effective, whole school approaches to mental health and wellbeing. Over 15,100 schools and colleges have received a senior mental health lead training grant, including more than 7 in 10 state-funded secondary schools in England.
In addition, we are providing £8 million to fund 24 existing early support hubs across the country – ranging from Exeter to Liverpool. This will improve access for children and young people to vital mental health support in the community, offering early interventions to improve wellbeing before their condition escalates further.
I hope this response is helpful. Thank you for bringing these concerns to my attention.
Sent To
- Department of Health and Social Care
Response Status
Linked responses
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56-Day Deadline
10 Jun 2024
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 29th April 2021 I commenced an investigation into the death of Axel Price aged 18. The investigation concluded at the end of the inquest on 9th October 2023. The overall conclusion of the inquest was a narrative conclusion which stated that: “At some time between the 15th April and 23rd April 2021 Axel, who had recently turned 18 years old tied a ligature
It cannot be determined if at the time he had intended to end his own life. On 22nd February 2021 Axel had an unplanned discharged from Hospital, following his arrest by Police, at a time when he was showing signs of a decline in his mental health. The agencies failed him in that:
1. The Mental Health services failed to arrange a coherent planned discharge on 22nd February 2021 and provide a clear risk, crisis, and care plan on discharge.
2. Adult Social Care failed to arrange a capacity assessment upon his discharge on 22nd February 2021 or anytime thereafter.
3. There was lack of consideration by all agencies involved with Axel as to whether the accommodation provided to him was suitable for a young person, whose capacity fluctuated when in crisis, and who in those circumstances became unsafe to live alone.
4. Axel’s lead Practitioner failed to assertively engage with Axel after discharge and meet with him in person. She was therefore not able to assess his ongoing risk or recognise his mental health deterioration.
5. On 6th April 2021 following an obvious decline in Axel’s mental health presentation there was a failure by Adult Social Care staff to arrange a full risk assessment and mental health review.
6. There was a lack of support and active engagement for Axel provided by the Adult Assessment and Treatment Service in Crawley pending his transfer to Adult Assessment and Treatment Service in Brighton. Axel’s death was contributed to by neglect”
It cannot be determined if at the time he had intended to end his own life. On 22nd February 2021 Axel had an unplanned discharged from Hospital, following his arrest by Police, at a time when he was showing signs of a decline in his mental health. The agencies failed him in that:
1. The Mental Health services failed to arrange a coherent planned discharge on 22nd February 2021 and provide a clear risk, crisis, and care plan on discharge.
2. Adult Social Care failed to arrange a capacity assessment upon his discharge on 22nd February 2021 or anytime thereafter.
3. There was lack of consideration by all agencies involved with Axel as to whether the accommodation provided to him was suitable for a young person, whose capacity fluctuated when in crisis, and who in those circumstances became unsafe to live alone.
4. Axel’s lead Practitioner failed to assertively engage with Axel after discharge and meet with him in person. She was therefore not able to assess his ongoing risk or recognise his mental health deterioration.
5. On 6th April 2021 following an obvious decline in Axel’s mental health presentation there was a failure by Adult Social Care staff to arrange a full risk assessment and mental health review.
6. There was a lack of support and active engagement for Axel provided by the Adult Assessment and Treatment Service in Crawley pending his transfer to Adult Assessment and Treatment Service in Brighton. Axel’s death was contributed to by neglect”
Circumstances of the Death
At some time between the 15th April and 23rd April 2021 Axel, who had recently turned 18 years old tied a ligature
. Axel had recently been detained under Section 2 Mental Health Act 1983 but discharged following a violent incident in the hospital when he was taken into Police custody. He was released from Police custody into temporary accommodation in Brighton provided by Adult Social Care.
. Axel had recently been detained under Section 2 Mental Health Act 1983 but discharged following a violent incident in the hospital when he was taken into Police custody. He was released from Police custody into temporary accommodation in Brighton provided by Adult Social Care.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.